DISEASES OF ORAL CAVITYDR MANPREET SINGH NANDAASSOCIATE PROFESSOR ENT

MMMC&H SOLAN

ORAL SUB MUCOUS FIBROSIS Chronic insidious painless process characterised as

dense white patch in oral cavity and pharynx due to juxtra epithelial deposition of fibrous tissue

Indian sub continent / genetic or racial Premalignant (40% of oral cancers) Age 20 – 50 yrs, F>M Etiology Paan/tobacco/spari (prolonged betelnut chewing) Cigarette/bidi smoking + alcohol Spicy food Nutritional def – iron, vitamin A,B, zinc, antioxidants Localised collagen disorder

Pathology Irritant -> subepithelial inflammation -> increased

production and decreased degeneration of collagen C/F Stage I – stomatitis – vesicles, ulcers, soreness and

burning sensation in mouth, intolerance to chillies/spicy food

Stage II – fibrosis – white fibrotic bands over soft palate, pillars, RMT, buccal mucosa, gradually progressive painless trismus

Stage III – sequelae - marked trismus, ankyloglossia, poor oro dental hygiene, leukoplakia, dysphagia, speech deficit, submandibular swellings

Diagnosis.... Blood – anaemia, ESR Biopsy after toluidine blue staining Gastric analysis Treatment Medical Local steroids – inj steroid (dexa 4 mg) + inj

hylase (1500 units) in 1 ml intra oral/ submucosal/ over fibrous bands once/twice a week for 6-8 weeks

Vitamins, zinc, antioxidants Good oro dental hygiene Avoid irritants/ jaw opening exercises

Surgical Incision/sectioning of fibrous bands and

grafting Grafts used – split skin graft, b/l tongue

flap, nasolabial flap, temporalis fascia graft, b/l radial forearm free graft

Lasers – KTP 532, CO2 to cut bands Condylectomy – for advanced cases of

trismus

LEUKOPLAKIA Clinical white patch that cannot be characterised

clinically and pathologically as any other disease and which cannot be rubbed off

Etiology Tobacco smoking/chewing (betelnut) Alcohol Spices Dental sepsis/ill fitting dentures Chronic sun exposure Chronic candidal infection/ viral/ SMF Vitamin def/plummer vinson syndrome M>F, age 30-40 yrs

Pathology – hyperkeratotic response to irritant C/F Mostly asymptomatic White, grey or yellowish surface with defined margins MC site – buccal mucosa and oral commissure Types Homogenous thin leukoplakia Nodular speckled leukoplakia with eryhtematous base Erosive / erythroleukoplakia – highly malignant, white

patches have erosions and interspaced with red patches

Proliferative/verrucous type – high recurrence, women

Prognosis 1-20% chance of malignancy. Depend on

age, duration and site (floor of mouth, ventral surface of tongue)

20% chance of recurrence Treatment Disappear spontaneously if irritant treated Incisional/excision biopsy Excision using scalpel/ cryotherapy/ laser/

electrocautery Antioxidants/retinoids/COX 2 inhibitors

ORAL HAIRY LEUKOPLAKIA Asymptomatic white lesion of oral cavity MC site – tongue margins. Others – dorsum

of tongue, buccal mucosa, floor of mouth Etiology – EB virus. Common in HIV/

immunocompromised Diagnosis Histology – hyperkeratosis Demonstration of EB virus – in situ/ PCR/

southern blot method Treatment Anti retroviral therapy

ERYTHROPLAKIA Red lesion which cannot be characterised

as any other lesion Bright red/ velvety red patch over lower

alveolus/ gingivobuccal sulcus/ floor of mouth

High malignant potential Clinically interspersed with leukoplakia Red colour due to decreased keratinisation

so red vascular connective tissue of submucosa shines

Treatment – excisional biopsy with regular follow up

TRISMUS Inability to open mouth Etiology Acute painless – tetanus, strychnine poisoning Acute painful – quinsy, alveolar inf of last molar, acute

otitis externa, acute parotitis, acute TM arthritis Chronic – SMF, burns, malignancy, ankylosis of TM

joint Staging I – 2.5 – 4 cm, II – 1 – 2.5 cm, III - < 1 cm, IV – total

closure Complications – dental sepsis, poor nutrition Treatment Reverse the cause Condylectomy

CANDIDIASIS/MONOLIASIS Etiology Candida Albicans – yeast like fungi. In

immunocompromised destruction of other organisms in oral cavity leads to overgrowth of candida and it becomes pathogenic

Risk factors – immunosuppression Overuse of antibiotics/steroids Post CT/RT Malignancy Elderly/ newborns/ pregnancy Cytotoxic drugs AIDS/ diabetes/ post renal transplant/ nutritional

deficient

C/F Asymptomatic Painful/odynophagia/interfere with swallowing

and chewing Burning sensation in mouth Diagnosis Gram stain – fungal hyphae KOH examination – branching hyphae Types Acute pseudomembranous candidiasis

(thrush) – infants/children/ immunocompromised White grey patch on oral mucosa and tongue

On wiping leaves erythematous mucosa Associated with inflammation of

surrounding mucosa Treatment Topical application of

Nystatin/Clotrimazole 1% gentian violet application Systemic antifungals – fluconazole,

ketoconazole, itraconazole IV amphotericin B

Chronic hypertophic candidiasis/ candidial leukoplakia

High incidence of malignancy MC site – anterior buccal mucosa Dense chalky plaque more thicker which

cant be wiped off Treatment Surgery – excision Long term anti fungal treatment –

nystatin, amphotericin B

Acute erythematous candidiasis – painful over hard palate

Chronic erythematous candidiasis – asymptomatic

Angular candidiasis – involves angle of mouth extends to skin (staphylococcal)

Median rhomboid glossitis – on dorsum of tongue in front of foramen caecum, asymptomatic, needs no treatment

HERPES SIMPLEX GINGIVO STOMATITIS Oro labial herpes Etiology Human Herpes Simplex Virus – I Found in muco cutaneous junction Spreads by contact, saliva Types Primary Affects 60-90% of population Common in children Fever, malaise, headache, sore throat and lymph

adenopathy Thin walled, delicate clusters of small multiple

vesicles

Seen on lips, buccal mucosa, palate which rupture and form ulcer surrounded by inflammation

Gingiva appears erythematous Painful lesion Resolves within 7-14 days Diagnosis Viral isolation and culture Cytological analysis of vesicle Serum antibody titres Treatment – topical anaesthetic mouth wash,

vitamins Avoid steroids - aggravate

Secondary/recurrent HSV infection Adults Etiology Reactivation of virus lying dormant in trigeminal

ganglion due to emotional stress, fatigue, fever, pregnancy, immunodeficiency, trauma

Sites Vermilion border of lips (Herpes labialis) MC Recurrent intra oral herpes (hard palate,

gingiva) C/F Painful, burning sensation

Pin sized clustered vesicles occur in erythematous and oedematous mucosa which rupture into ulcer after 1-2 days, crusting for 5-7 days and heal without scar formation

Treatment Topic acyclovir/pancyclovir cream Tab acyclovir 200 mg 5 times a day for 5

– 6 days No role of steroids

RECURRENT APHTHOUS ULCERS Recurrent ulcerative stomatitis/ Canker

sores MC non traumatic form of oral ulcer

involving oral cavity and oropharynx Ulcers are superficial and shallow in

mobile areas – lips, tongue, buccal mucosa

Very painful Women aged 10 – 30 yrs MC site – lower vestibule Not involve hard palate, gingiva

Etiology Local physical trauma Psychological effect/stress Food allergy – nuts, spices, tomatoes,

chocolates Drug induced – NSAID, beta blockers,

potassium channel blockers Vitamin deficiency – B12, folic acid, iron Hormonal/endocrine disturbances UV light Viral/HIV/ ulcerative colitis Habitual constipation

C/F Recurrent often multiple painful and

superficial ulcers in oral cavity and oropharynx

Increased salivation Painful articulation and swallowing No symptoms of fever, malaise and

lymphadenopathy Types Minor ulcers (85%) – small multiple 2-5 mm

with central necrotic area surrounded by red halo, for 7-10 days, heals without scar

Major (10%) – single ulcer > 2-4 cm, post part of oral cavity, very painful, takes 3-6 weeks, heals with scar

Herpetiform (5%) – tiny ulcer occur close together and coalesce to form large ulcer, multiple, take 7-10 days, heal without scar

Treatment Avoid spicy food Vitamin supplements Topic lignocaine gel/steroids-

oral,intralesional,lozenges Cauterisation of base of ulcer with 10% silver nitrate,

TCA Tab tetracycline 250 mg dissolved in 50 ml of water

5 times a day, rinse it and then swallow it

TONGUE TIE/ANKYLOGLOSSIA Tongue protusion restricted beyond

lower incisors Treatment Transverse release and vertical closure –

thick tie Simple incision – thin mucosal folds

CARCINOMA OF ORAL CAVITY Epidemiology MC malignancy in Indian subcontinent Types SCC 90% MC Salivary gland tumours (adenoid cystic ca) Verrucous ca (ackerman’s tumour) Sarcoma Lymphoma Age > 40 yrs M>F (4:1)

Etiology Smoking – reverse smoking (hard palate), pipe

smoking (lips) Spirit (alcohol) Spices Spari (betelnut) kept in mouth Sharp and septic tooth Syphilis Dietary deficiency UV light exposure (lips) HPV Immunocompromised

Premalignant lesions Leukoplakia/erythroplakia/SMF Candidiasis Plummer vinson syndrome Lichen planus (lips) Sites Lateral margins of tongue (mc) Other common sites are buccal mucosa,

floor of mouth

Pathology Gross Exophytic/proliferative – cauliflower like Endophytic/ulcerative- everted irregular edges Ulceroproliferative Infiltrative – deep spread Histology Verrucous – very well diff Well differentiated - >75% diff Moderately differentiated – 50 -75% differentiation Poorly differentiated – 25-50% , anaplastic - <

25% diff

TNM Staging T (primary tumour) Tx – cant be assessed T0 – no evidence of primary tumour T1 – upto 2 cm in greatest dimension T2 - >2 upto 4 cm in greatest dimension T3 - > 4 cm in greatest dimension T4 (lip) – involves cortical bone, inferior alveolar

margin, floor of mouth, skin of face T4a – involves adjacent skin, cortical bone, deep

tongue muscles, skin of face T4b – involves skull base, pterygoid plates,

encases ICA

N – Regional lymph node size in greatest diameter

Nx – cant be assessed N0 – no regional ln metastasis N1 – single I/L LN upto 3 cm N2a – single I/L LN >3 cm upto 6 cm N2b – multiple I/L LN upto 6 cm N2c – B/L or C/L LN upto 6 cm N3 – LN>6 cm M – Distant Metastasis – Mx – cant be

assessed/ M0 – no distant metastasis/ M1 – distant metastasis

Staging 0 – Tis N0 M0 I – T1 N0 M0 II – T2 N0 M0 III – T3 N0 M0/T1-3 N1 M0 IV a – T4a N0-1 M0/T1-4a N2 M0 IV b – T4b N0-2 M0/T1-4b N3 M0 IV c – T1-4 N0-3 M1

C/F Lips – MC site between midline and commissure of

lower lip, spreads to submandibular and submental lymph nodes

Gingiva/alveolar ridges – MC site – lower jaw in premolar region, spreads to submandibular and upper deep jugular ln

Hard palate – mc is adenoid cystic ca, lymph node metastasis late and less common

Oral tongue – mc site – middle 1/3rd of lateral border, spread to submandibular, upper deep cervical and from tip to submental lymph nodes

Cause referred ear ache (lingual nerve), odynophagia, ankyloglossia, painful

Floor of mouth – submandibular swelling (duct), submandibular, upper jugular ln

Buccal mucosa – 2nd mc site- angle of mouth, trismus, 50% lymph node metastasis

RMT – trismus Verrucous ca – mc site is lower buccal mucosa, low

grade SCC Mandible – if involved periosteal thickening,

tenderness, non healing tooth socket Diagnosis – Biopsy – punch/excision/wedge FNAC of ln swelling X Ray Mandible, OPG, CT Scan Chest X Ray – pulmonary metastasis

Treatment Surgery RT CT Factors deciding – Site – floor of mouth, gingiva – RT avoided –

risk of osteoradionecrosis, lips – RT preferred TNM staging Histology – adenocarcinoma – radioresistant Age Lifestyle Medical status

Stage I and II – wide local excision with adequate margins and primary closure/ Concomittant CT RT

Stage III and IV – COMMANDO OPERATION – Combined mandibulectomy

(marginal/hemi/total), tumour resection and Neck dissection

Tongue – partial/hemi/total glossectomy Reconstruction Muscle flaps – PMMC, trapezius, latissimus

dorsi, SCM Free flaps – radial forearm

Neck N0 – clinically negative Elective/functional neck dissection – level I,II,III,IV

with preserving of IJV, accessory nerve, SCM In case of positive nodes more than 2 or extra

capsular spread – post op RT Elective RT N1,N2a,N2b – RND/MRND followed by post op RT Radical RT N2c – operable – RND I/L side and C/L side IJV

sparing ND followed by post op RT Inoperable – Radical RT N3 – Radical RT

Adjunctive CT Photodynamic therapy Organ preservation therapy Speech or swallowing rehabilitation Pain management/palliative therapy Prognosis 5 yr survival rate 50-57% Late presentation Risk of secondary primary tumour Distant metastasis via blood..... Infiltrative type – poor prognosis.......